Provider Demographics
NPI:1457797342
Name:WYNN, RACHEL MICHELLE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:MICHELLE
Last Name:WYNN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:MICHELLE
Other - Last Name:RATLIFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3152 REDSTONE LN
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-7170
Mailing Address - Country:US
Mailing Address - Phone:512-537-4001
Mailing Address - Fax:
Practice Address - Street 1:3152 REDSTONE LN
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-7170
Practice Address - Country:US
Practice Address - Phone:512-537-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist